Presentation on Phantom Limb treatment. "PLP"

1. Phantom Limb Pain
Treatment
By:
R A Candra Putra (5718035)
Auntouch T (5718036)
Harashdeep Grover (5718037)
Rina F Rahmawati (5718038)

2. Contents
• Introduction
• Causes
• Treatment
– Pharmacological Treatment
– Nonpharmacological Treatment
– Surgical Treatment
• Conclusion

3. The concept of Phantom
Limb Pain as being in pain
that feels like it's coming
from a body part that's no
longer there.
Doctors once believed
this post-amputation
phenomenon was a
psychological problem, but
experts now recognize that
these real sensations
originate in the spinal cord
and brain.
The concept of Phantom
Limb Pain as being in pain
that feels like it's coming
from a body part that's no
longer there.
Doctors once believed
this post-amputation
phenomenon was a
psychological problem, but
experts now recognize that
these real sensations
originate in the spinal cord
and brain.
Introduction

4. •The exact cause of phantom pain is unclear, but it appears to
originate in the spinal cord and brain.
•During imaging scans — such as magnetic resonance imaging (MRI)
or positron emission tomography (PET) — portions of the brain that
had been neurologically connected to the nerves of the amputated
limb show activity when the person feels phantom pain.
•A number of other factors are believed to contribute to phantom
pain, including damaged nerve endings, scar tissue at the site of the
amputation and the physical memory of pre-amputation pain in the
affected area.
•The exact cause of phantom pain is unclear, but it appears to
originate in the spinal cord and brain.
•During imaging scans — such as magnetic resonance imaging (MRI)
or positron emission tomography (PET) — portions of the brain that
had been neurologically connected to the nerves of the amputated
limb show activity when the person feels phantom pain.
•A number of other factors are believed to contribute to phantom
pain, including damaged nerve endings, scar tissue at the site of the
amputation and the physical memory of pre-amputation pain in the
affected area.
Causes

5. PHARMACOLOGICAL TREATMENT

6. PreEmptive Analgesia and Anesthesia
absence of sensibility to pain,
particularly the relief of pain without loss
of consciousness;
or noxious stimulation.
absence of sensibility to pain,
particularly the relief of pain without loss
of consciousness;
or noxious stimulation.
Lack of feeling or sensationLack of feeling or sensation
AdvantagesAdvantages
•Stable intraoperative conditions (e.g.
Cardiovascular)
•Effective
•Reduced nausea and vomiting
•No effect on urinary function.
•Improved early mobilization of major
joints.
•Stable intraoperative conditions (e.g.
Cardiovascular)
•Effective
•Reduced nausea and vomiting
•No effect on urinary function.
•Improved early mobilization of major
joints.
•Time consuming –takes around 15-30
minutes to be effective
•Failure rate about 5% even in the
best hands.
•Inadequate training of consultants
and trainees.
•Time consuming –takes around 15-30
minutes to be effective
•Failure rate about 5% even in the
best hands.
•Inadequate training of consultants
and trainees.
Disadvantage
s
Disadvantage
s

7. Acetaminophen and Nonsteroidal Anti-Inflammatory
Drugs
( NSAIDs )
 A cross sectional study found that acetaminophen and NSAIDs were the
most common medications used in the treatment of PLP .
 The analgesic mechanism of acetaminophen is not clear but serotonergic and
multiple other central nervous system pathways are likely to be involved.
 NSAIDs inhibit the enzymes needed for the synthesis of prostaglandin and
decrease the nociception peripherally and centrally.
 One of the major side effects is that they decrease the effect of the normal
blood clotting factors in blood.
 A cross sectional study found that acetaminophen and NSAIDs were the
most common medications used in the treatment of PLP .
 The analgesic mechanism of acetaminophen is not clear but serotonergic and
multiple other central nervous system pathways are likely to be involved.
 NSAIDs inhibit the enzymes needed for the synthesis of prostaglandin and
decrease the nociception peripherally and centrally.
 One of the major side effects is that they decrease the effect of the normal
blood clotting factors in blood.

8. Opioids (Morphine)
• Bind to CNS and PNS
• Provide analgesia
without loss of touch,
proprioception, or
conciousness
• Effective for
treatment
neuropathic pain
including PLP,
Diminish cortical
reorganization (Huse E
2001)
• Controversial and
their use is limited
due to the side effects
and potential for

9. Tricyclic Antidepressant (TCAs)
• Commonly used for
neuropathic pain
• Analgesic – inhibition of
serotonin-norephineprine
uptake blockade
• Average dose of 55mg of
amitriptyline is effective to
control PLP
• Nortryptyline and desipramine
equally effective with less side
effects
• Side effects - cardiotoxicity,
orthostasis, tachycardia,
arrhythmias, insomnia,
dizziness, weight gain, and
anticholinergic effects

10. Anticonvulsants
• Anticonvulsants - prevent or reduce the severity and
frequency of seizures in various types of epilepsy but
which are also effective for pain. They work in a
number of different ways, all of which have relevance
to their effect on pain.
• Gabapentin – show positive result in controlling PLP by
inhibitory action at voltage-gated calcium channels The
most common side effects were dizziness and
somnolence, but weight gain, nausea, abdominal pain,
asthenia,
• Carbamazepine has been reported to reduce pain
associated with PLP
• Oxcarbazepine and pregabalin – need further studies

11.  NMDA receptors play a role
in sensitization at the spinal
cord level
 memantine produce an
analgesic effect that may be
beneficial in the treatment
of PLP
 it may be successful in
treating PLP if initiated in
early post-amputation
period(Hackworth, et al
2008)
Calcitonin
NMDA receptor
antagonists Calcitonin is a peptide with
high a molecular weight.
 The exact mechanism of
action is still unclear
(Eichenberger, et al 2008)
 But it leads to decreased
formation of local cytokines
and prostaglandin
 It may reduce the intensity
and frequency of pain;
however, a more recent
randomized, controlled trial
showed that calcitonin alone
was ineffective against PLP

12. Other medications
• The beta blocker propanolol and the Ca
channel blocker nifedipine - used for
treatment PLP. However their effectiveness is
still unclear

13. NONPHARMALOGICAL TREATMENT

14. Treatment of Phantom pain (PLP)
• Nonpharmacological
treatment
• Transcutaneous
Electrical Never
Stimulation (TENS)
- Standard device ,
inexpensive
- Safe and easy to
use
- Using battery to
control
- Generates to the
skin to activate the
effected nerves.

15. Mirror Therapy
• was first introduced by
Ramachandran in 1996
• persons with amputated limb use
either a mirror or mirror box to
reflect an image of the intact
limb. It is hypothesized that this
works by preventing cortical
restructuring
• patients with PLP showed a
decrease in pain at the 6-month
follow-up (Diers, 2010)
• mechanisms underlying the
effects of mirror training or motor
imagery, are still unclear

16. Biofeedback
– It can help to reduce
muscle tension and
increase blood flow.
– by using visual or
other sensory stimuli to
retrain the brain to stop
sending pain signals
Prosthesis
- Help to regain the feeling
of loosing limb
- An electrical prosthetic
limb moved by signals.
Prosthesis
- Help to regain the feeling
of loosing limb
- An electrical prosthetic
limb moved by signals.

17. SURGICAL INTERVENTION
• Should be avoided
• Stump Revision
– Patients with continued
phantom limb pain
– Stump with vascular
insufficiency
– Infection
– Neuromas may undergo
stump revision

18. Surgical
Remove the nerve sending the pain signals
• Neurectomy : Nerve
removal
• Rhizotomy : sever nerve
roots in the spinal cord
• Cordotomy : sever nerve
cord in the spinal cord
• Lobectomy
• Patient experience
numbness, tingling or
impairment of the
surrounding nerves
• May provide short term
relief but pain
commonly reappears

19. Surgical Dorsal Root Entry Zone
• Phantom pain because of brachial
plexus avulsion, sacral plexus
avulsion or Spinal Cord Injury
• Dorsal root : nerve fibers send
the brain messages about
sensations and pain
• Destroying the area where
damaged nerves join the central
nervous system. This intercepts
pain messages from nerves to the
brain
• Most patients experience relief of
pain immediately after surgery
• Sustain good pain relief
over the long term

20. Conclusion
• Multidisciplinary approach, tailored to the individual needs of
the patient, has the best chance of improving the symptoms
of phantom limb pain and the functional outcome
TENS
Acupuncture
Bio-feedback
Hypnosis
Massage
Ultrasound
ECT
Nerve blocks
Neurectomy
Stump revision
Rhizotomy
Cordotomy
Lobectomy
Sympathectomy
Spinal cord stim
Brain stimulation
TCA
Anticonvulsants
Lidocaine
Opioids
NMDA antagonists
clonidine

21. THANK YOU FOR
YOUR ATTENTION